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1、姓名：xxx職 業(yè)：XXX性別：x工作單位：年齡：X 歲住 址：XXXXX婚姻：X 婚供 史 者：XX（與患者關(guān)系）出生地：xx入院時間：XXXX 年 X 月 X日X 時 X 分民族：XX記錄時間：XXXX 年 X 月 X日X 時 X 分主 訴：XXXXXXXXXXo現(xiàn)病史：XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX X XXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX X X X X X X X X X X X X X X X X X X X X X X XXXXXXXXXXX X X X X X X X XX X X

2、 X X X X X X X X X X X X X X X X X X X X XXXXXXXXXXX X X X X X X X XX X X X X X X X X X X X X X X X X X X X X X X XXXXXXXXXXX X X X X X X X XX X X X X X X X X X X X X X X X X X X X X X X XXXXXXXXXXX o既往史：X X X X X X X X X X X X X X X XXXX X X X X X X X X X X XX X X X X X X X XX X X X X X X X X X X X

3、 X X X X X X X X X X X XXXXXXXXXXX X X X X X X X XX X X X X X X X X X X o個人史：X X X X X X X X X X X X X X X XXXX X X X X X X X X X X XX X X X X X X X XX X X X X X X X X X X X X X X X X X X X X X o家族史：XXXXXXXXXXXXXXXXXXXXXXXXXo體格檢查T：x. xcP：x 次/分R：x 次/分BP：X/xmmHgXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

4、XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

5、xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

6、xxxxxxxxxxxxxxxxxxxxxxxxxxxxxx XXXXXXXXXXXXXXXXXXXXXXo實(shí)驗(yàn)室及器械檢查xx（xxxx-X-x,x 院）初步診斷：XXXXXXXXXXXXXXXXXXXXXXXXXXXX醫(yī)師簽名：XXXXXXX 年 X 月 X日上級醫(yī)師職稱及簽名（手工書寫）XXXX 年 X 月 X日X 時 X 分 首次病程記錄XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX。其病例特點(diǎn)及診斷依據(jù)總結(jié)如下：一、病例特點(diǎn)： XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

7、XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

8、XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXX。二、初步診斷： XXXXXXX XXXXXXXXXX XXXXXX XXXXX三、診斷依據(jù)： XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

9、XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXX。四、鑒別診斷（擬診分析）：XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

10、XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXX。五、診療計(jì)劃： XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXX。XXXX 年 X 月 X日 上級醫(yī)師職稱及簽名（手工書寫）/醫(yī)師簽名：XXXXXXX 年 X 月 X日X 時 X 分 XXX 主治醫(yī)師查房記錄XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

11、xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxx 年 x 月 x日xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

12、xxxxxxxxxxxxxxxxxxxxxxx 年 x 月 x 日xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

13、xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx。上級醫(yī)師手工簽名x 時 x分 xxx 副主任醫(yī)師查房記錄xxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx xxx

14、xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx上級醫(yī)師手工簽名x 時 x分xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

15、xxxxxx xxxxxxxxx/醫(yī)師簽名：xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx。/醫(yī)師簽名：xxxXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXX X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X XXXX X X X X X X X X X X X X X X

16、X X X X X X X X X X X X X X X X X X X X X X X X XXXX X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X XXXX X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X XXXX X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 。醫(yī)師簽名：X X XXXXX 年 X 月

17、 X 日 X 時 X 分 XXX 主治醫(yī)師查房記錄XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX。 上級醫(yī)師手工簽名/醫(yī)師簽名：XXX XXXX 年 X 月 X 日 X 時 X 分 XXX 副主任醫(yī)師查房記錄XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

18、XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX。上級醫(yī)師手工簽名/醫(yī)師簽名：XXX入院診斷： XXXXXXXXXXXXXXXXXXXXXX手術(shù)名稱： 出院診斷： XXXXXXXXXXXXXXXXXXXXXX入院時情況（簡要病史、陽性體征、有關(guān)實(shí)驗(yàn)室及器械檢查結(jié)果）XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

19、XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXX。出院醫(yī)囑：XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX。醫(yī)師簽名：XXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X XXXX XXX X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X XXXX XXX X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X XXXX XXX X X X X X X X X X X X X X X X X X X X X X X X X X X

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